Provider Demographics
NPI:1225146038
Name:LEDTKE, MICHAEL ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:LEDTKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8148 FARMHURST LANE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236
Mailing Address - Country:US
Mailing Address - Phone:989-793-7779
Mailing Address - Fax:989-793-7137
Practice Address - Street 1:8148 FARMHURST LANE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236
Practice Address - Country:US
Practice Address - Phone:989-793-7779
Practice Address - Fax:989-793-7137
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038648207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0737374OtherBCBS
MI0737374OtherBCBS
B46506Medicare UPIN